How is the CPAP type determined for Medicare participants?

[Wonka]

I'm having my second sleep study this Thursday. At the sleep clinic, they showed me the machine (which appeared very old and large) and two different types of masks only. I know there are many different types of masks and machines. My guess is each insurance company chooses the manufacturer they contract with and that's what you get...I suppose Medicare does the same. So, if your insurance company is paying they determine the type of CPAP and Mask you will you use? Is that correct? I hope not.

Since it appears imminent I'll be using one of these devices very soon, I'd like to make sure I'm getting the most current equipment and masks that's best for my needs. How do I do that? For example, in my brief research I found a product called Cireadiance Sleepwear Advance a soft cloth mask that looks like it might work well for restless sleepers also sleeping on their side (me on both).

Any input would be appreciated.

[Janknitz]

Wonka,

You need to understand some things about Medicare now, so you don't get bamboozled.

First, it's important to know if you have traditional Medicare Parts A and B with a supplement/Medi-gap policy. If so, then the rest applies:

Medicare pays for CPAP machines by billing codes and all CPAP/APAP machines are under the SAME billing code which is E0601. Medicare sets the allowable amount in each state and pays 80% of that amount REGARDLESS OF HOW MUCH THE DME WANTS TO CHARGE FOR THE MACHINE. You are only responsible for the other 20%, NOT the full price the DME wants to charge, and often your supplemental/Medigap insurance pays part or all of your share (you may or may not owe a co-pay or a deductible to your supplemental insurer).

This means you can get ANY CPAP/APAP machine you want. ANY.. Medicare will pay the same amount no matter if you get the oldest, dumbest brick or the fanciest newest machine. You will pay the same amount too. Same with masks. Medicare will pay for ANY mask.

So, it's not the insurer who cares what machine you get, it's the DME provider, because if they can pawn an old dumb machine off on you, they make more money.

Read my blog here http://maskarrayed.wordpress.com/what-y ... me-part-i/ for a more thorough explanation.

Don’t let the DME pull any games with you. Check in with your supplemental insurance/Medi-gap provider to see if you need to use a “preferred provider” for the supplemental insurer to pay more, and find out what DME’s are “in network” if that’s the case. Otherwise you can use any DME you want, and you don’t have to stick with someone who tries to pawn an old brick of a machine on you and limit your choice of masks. You can have whatever you want.

You should also be aware that while Medicare purchases the humidifier, hose, mask, and filters, it does not purchase the machine outright. It requires a “capped rental”, meaning Medicare will rent the machine for 13 months, after which time the machine is yours (sort of “rent to own”).

[Wonka]

Thanks for the quick and informative reply. I have AARP Supplemental insurance in addition to Medicare. I'll contact them tomorrow to find out more about the DME they use.

That brings me to the next question. Which current machine is the most preferable? I noted the soft cloth CPAP mask which looks to me like it would be the most tolerable...how do I ensure that's what I get (if I can find it again on the internet, it appeared to be a UK website)

[The Texan]

Do your homework, here on the forum, then you decide which mask and machine you want and don't back down. I spent many hours here listening to what everyone had to say and decided I wanted a Respironics M series auto and a pillow mask. When the sleep doc wrote the Rx it was very generic, but I told the DME what I wanted and was not going to accept anything else. Had to go to 3 different DMEs before one said OK and gave me what I wanted. With Medicare, you are the driver, not the DME and you can go to any DME you choose, so don't take no for an answer.

[Janknitz]

At the very least you must insist on a DATA CAPABLE machine--that's efficacy data (how well the machine works for you by reporting your AHI and leak rates), and if your doctor recommends CPAP you can get either a CPAP or an APAP. Most prefer APAP's because they are more versatile (they can be used in CPAP mode), but that's a matter of personal preference.

Do some sluething here to find out which machines are data capable and what bells and whistles they have. Start by clicking the Lightbulb for the CPAP Wiki and read up so you understand what you are reading.

You want the Sleepweaver mask by Circadiance and that is the one mask that might be difficult since very few DME's carry it. You may find a DME who will order it for you, or you may have to mail order it on your own (in which case Medicare and AARP will NOT pay for it).

You should be aware that while some people really love this mask because it has no hard parts, it is very difficult to fit, especially for a newbie. You are better off for your first mask to get something more easily obtained from a DME with a generous mask return policy, so that you can keep trying masks until you find what works for you. If NOTHING works, that's the time to try the Sleepweaver, and by that time you will have enough experience with masks to deal with the minute adjustments that are necessary to keep a mask like that from leaking.

[Wonka]

I tried posting this response earlier, but didn't see it when I returned to the website. So, I'm posting it again. Please excuse me if it results in a duplicate post.

Great responses, please keep them coming!

Texan - I believe you're saying that as a Medicare recipient I can choose the DME, is that correct? If so, what about the AARP Supplemental policy...is the DME still my choice for reimbursement of the amount medicare doesn't cover? I'll try to get more information from AARP tomorrow. I do want to get what's best for me...not the pocketbook of the provider.

Janknitz - I will make sure I'm provided a data capable machine, and will consider your advice on the Sleepweaver product (I probably won't be able to obtain it anyway), but it did look like it would be the most comfortable (if any mask can be comfortable).

[The Texan]

I tried posting this response earlier, but didn't see it when I returned to the website. So, I'm posting it again. Please excuse me if it results in a duplicate post.

Great responses, please keep them coming!

Texan - I believe you're saying that as a Medicare recipient I can choose the DME, is that correct? If so, what about the AARP Supplemental policy...is the DME still my choice for reimbursement of the amount medicare doesn't cover? I'll try to get more information from AARP tomorrow. I do want to get what's best for me...not the pocketbook of the provider.
Yes, I am speaking as a medicare participant and you can choose your DME. Your supplement has no say about who you use either, as they pay secondary to medicare and if medicare approves they are required to pay their share. I agree, get a fully data capable machine, not one that give basic compliance info only. If you start trying to get excotic items, then you may run into problems and delays, keep that in mind.

Janknitz - I will make sure I'm provided a data capable machine, and will consider your advice on the Sleepweaver product (I probably won't be able to obtain it anyway), but it did look like it would be the most comfortable (if any mask can be comfortable).

[Emilia]

Our host site carries the Sleepweaver mask, and if you buy the return insurance, you can return it for a full refund within 30 days. So...for future reference, you might want to give it a try and be able to return it if it doesn't work out for you. I have one, and I was very lucky to have a good fit with it. I had a minor leak at the bridge of the nose, but I was able to fix that with some padded mole skin to that area. It is a wonderfully comfortable nasal mask, but I have moved on to the Swift LT for Her pillow mask. The Sleepweaver is in reserve for me should I need a break from the pillows.

Be sure to research the fully data capable machines (those that provide full efficacy data). To access that info, you will need to get the software for the machine you receive, but do NOT tell the doctor or DME that is your goal. They will tell you you don't have access to that info.... NOT TRUE, but we'll help you with that when the time comes.

Remember that an Auto Adjusting Cpap machine is preferable since it can be run in either auto or straight cpap modes. The most popular auto machines used by members of this forum are all fully data capable.... ResMed S9 Autoset; PR System One REMstar; IntelliPAP AutoAdjust w/Smartflex; and a few older models, some of which obtaining the software or card readers is now becoming hard to do. The first three listed are current models and all three have efficacy software available.

Best of luck!! Keep us posted on your progress through the insurance/DME/fun and games......

[Wonka]

Emilia-

Be sure to research the fully data capable machines (those that provide full efficacy data). To access that info, you will need to get the software for the machine you receive, but do NOT tell the doctor or DME that is your goal. They will tell you you don't have access to that info.... NOT TRUE, but we'll help you with that when the time comes.

OK. Can you explain why the Docs wouldn't want to help me obtain the required software? Is the efficacy SW something where the adjustments can be made by the patient, cutting profit margins for the Doc, or what?

Is it all about money? How sad.

[Janknitz]

I've never had contact with the actual "sleep specialist" at Kaiser, but the RT's at Kaiser here in Santa Rosa have been great and actually cheered me on for getting software and access to my data.

Kaiser is sort of an interesting animal when it comes to SA. (I recognize that not every Kaiser center has the same attitude, YMMV). The more SA they treat, the better the compliance, theoretically, the more money they save by avoiding later downstream, serious effects of untreated SA. So they are actually proactive in the diagnosis and treatment, because it will ultimately benefit their bottom line. They are also very proactive about patient education, rather than throwing the machine at you and telling you to just use it.

Another problem I have is asthma, and in addition to the usual group patient education programs they had me work individually with an asthma case manager who spent a huge amount of time with me getting my asthma under control, helping me manage medications and situations (my supposedly scent-free office environment wasn't and it was killing me!), and monthly phone appointments to make sure I was doing well. This would have cost me a fortune outside of the Kaiser system, and I wasn't even charged a co-pay.

And, since they don't make any extra money for interpreting your data or making changes to your machine, they don't feel threatened having you play an active role in your treatment and getting access to data. It doesn't hurt their pocket if you take charge of your own care. Meanwhile, they have been great about squeezing me in and seeing me if I'm having any problems and generous with the sample masks until I found THE mask (unfortunately, one that is not on Kaiser's formulary ).

I'm not the biggest Kaiser fan in the world, but I tend to sound like one here, because I'm mostly impressed with the sleep lab staff and approach, as well as the asthma care. I have my complaints, too, but overall I think it's a lot better than people out in the real world seem to be experiencing and a whole lot less expensive for me.

[Emilia]

The software is technically for doctors/DME's/RT use, not patients. However, we believe in patient empowerment on this forum and take pride in obtaining and using said software. It can be had, and our host site even sells some software, but they have the disclaimer that it is not intended for patient use. Many DME's will get quite huffy about patients adjusting things or monitoring. Some will tell you 'You don't need to know that." Some will tell you the machine can't be adjusted! Imagine telling a diabetic patient they can't monitor their glucose or adjust their insulin..... Why cpap is any different is a mystery, but there you have it...... On the other hand, my sleep doc is thrilled I have the software and can monitor my own therapy....he wishes all his patients were as proactive as I am!

[snuginarug]

I may be repeating what others have said, if so, please forgive.... Mask choice is really important. Well, actually information about mask returns is really important. Most mask makers provide a 30 day return policy. (I do not know about the particular mask you want, I have never heard of that brand.) This means you can usually try out mask after mask, one after another, in a search for the right one. Everyone is different. What is good for one person may not be good for another. The mask is your interface with the machine, and affects your ability to be compliant. If the mask is uncomfortable, your whole experience is uncomfortable. I certainly hope you get a good DME, and that they will help you in any way that is possible. But some people have problems with getting their DME to return calls promptly. This can cause great havoc with the mask issue... they don't call you back, your 30 days runs out, you are stuck with a dissatisfactory mask. Make sure you know when the 30 days runs out, and keep on them if they are dilatory in returning your calls. It is your right to take advantage of the 30 day return policy. Some places get tired of going through the mask choosing process and want to get you to keep a dissatisfactory mask to save themselves trouble. Keep at it until you find the right one.

All this doom and gloom about bad DMEs may prove inapplicable for you. You might luck out and get a great DME like me. Go in with an open mind and see how they treat you. Forewarned is forearmed, and you will be equipped with the information you need if you do your research.

I wish you very good luck!

[BlackSpinner]

Emilia-

Be sure to research the fully data capable machines (those that provide full efficacy data). To access that info, you will need to get the software for the machine you receive, but do NOT tell the doctor or DME that is your goal. They will tell you you don't have access to that info.... NOT TRUE, but we'll help you with that when the time comes.

OK. Can you explain why the Docs wouldn't want to help me obtain the required software? Is the efficacy SW something where the adjustments can be made by the patient, cutting profit margins for the Doc, or what?

Is it all about money? How sad.

All about money for the DME. If they sell you a dumb brick they get more profit. Make sure you have the list of the actual detailed machine names you want in your hand and do not accept substitutes. Act like you would be buying a used car - trust no-one. In fact a used car sales man would at least know his products, you are safer and more protected on a used car lot them in a DME! No used car salesman will suggest you have no need to test drive a car.

[snuginarug]

Make sure you have the list of the actual detailed machine names you want in your hand

This is important, as some machines have very tricky names... "plus" is non data capable, but "pro" is, things like that. It is easy to get mixed up when under pressure.

[tigeragent]

I may be repeating what others have said, if so, please forgive.... Mask choice is really important. Well, actually information about mask returns is really important. Most mask makers provide a 30 day return policy. (I do not know about the particular mask you want, I have never heard of that brand.) This means you can usually try out mask after mask, one after another, in a search for the right one. Everyone is different. What is good for one person may not be good for another. The mask is your interface with the machine, and affects your ability to be compliant. If the mask is uncomfortable, your whole experience is uncomfortable. I certainly hope you get a good DME, and that they will help you in any way that is possible. But some people have problems with getting their DME to return calls promptly. This can cause great havoc with the mask issue... they don't call you back, your 30 days runs out, you are stuck with a dissatisfactory mask. Make sure you know when the 30 days runs out, and keep on them if they are dilatory in returning your calls. It is your right to take advantage of the 30 day return policy. Some places get tired of going through the mask choosing process and want to get you to keep a dissatisfactory mask to save themselves trouble. Keep at it until you find the right one.

Question on this.....

I went to a horrible DME provider 2 weeks ago that set me up with a S9 Escape Auto and Swift LT (even though my dr. specifically prescribed the FX). I found another DME provider in my insurance network that will give me the S9 Autoset and Swift FX. I have decided to switch to the new DME provider. The provider told me at the time that I have a 30 day window to bring back the mask. Does this imply that I HAVE to get a new mask from the same provider??? When I called the old provider yesterday to let them know I would be dropping off the machine and mask tomorrow, they told me that the mask could not be returned since it was for single patient use. I told them that I was advised of the 30 day mask return policy, but the person I spoke with is claiming ignorance. I just want to make sure my insurance will pay for the new mask, headgear, pillows, etc.